Regulation of Emergency Medical Services:  Phase Two

Executive Summary

December, 1999

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Executive Summary

 

            The committee authorized a scope of study regarding the regulation of emergency medical services on March 9,1999.  The focus of the examination targeted the three cornerstones of business regulation of emergency medical services:

·       assignment of exclusive service areas for emergency ambulance providers – called primary service areas (PSAs);

·       setting of maximum rates providers are allowed to charge; and

·       determination of need for license and certification.

The scope called for an identification of areas in need of change and proposed legislation that could be acted upon in the 1999 legislative session.  Subsequently, phase one of this report was issued in May 1999 and focused primarily on the designation of PSAs.  The committee found there was need for some corrections in the system, but concluded radical alternatives would be more disruptive than remedial to a system in place for more than 20 years. 

The recommendations contained in the previous report maintained the current regulatory system and the assignment of PSAs, but proposed policy enhancements to improve the ability of both local and state government to perform oversight functions of emergency medical services.  The committee’s eight recommendations were incorporated in sHB 6662 but did not pass during the last session.  The committee also authorized a second phase of the EMS study to examine areas the regulatory components it was unable to fully consider during phase one because of its abbreviated time frame.

This report, phase two, addresses the two other regulatory components of the EMS system -- rate setting and determination of need.  In addition, this report describes emergency medical dispatch and examines the need for basic data collection. 

Overall, the committee found the state’s regulatory mechanisms have not kept pace with the changes in the health care marketplace or the emergency medical services field.  Specifically, some of the committee findings include:

·       rate setting by DPH has not been very effective in keeping overall ambulance costs down - between 1994 and 1998 they rose at double the rate of increases in the consumer price index for either health care or transportation;

·       setting maximum rates does not appear to have standardized costs - rates charged among top commercial providers vary by 20 to 25 percent;

·       the current rate-setting process is based on a cost-plus system, providing no incentive to keep costs down;

·       DPH does not evaluate the needs of the entire EMS system but only reviews the needs of individual providers;

·       very few other states have a determination of need process and DPH does not engage in any retrospective review of the market or how well need is being met;

·       standards used by DPH to make need decisions are unclear and inconsistent;

·       there is no basic descriptive information on the state's EMS system and no data are collected to evaluate the system, even though statutes have required a data system be in place since 1975; and

·       less than half of the state's 9-1-1 communication centers have access to emergency medical dispatch - a proven technique used to save lives and promote the optimal allocation of EMS resources.

At its December 16, 1999, meeting the committee adopted eight recommendations.    The recommendations serve to: streamline the current regulatory requirements for rate setting and determination of need; raise the level of Medicaid reimbursement for ambulance transports; improve the collection of essential performance data; and expand the availability of emergency medical dispatch throughout Connecticut.  In addition, the report addresses concerns about how the Department of Public Health (DPH) has discharged EMS regulatory duties.  The approved recommendations are listed below.

Recommendations

1.  Rates currently filed and approved by the Department of Public Health would remain in effect.  Effective July 1, 2000, regulations concerning rate filing (Sec. 19a-179-21(f)) shall be modified to require only charging providers who wish to increase rates to submit complete financial information currently required by regulation.  Rate increase requests could be filed at any time, but no more than annually. Detailed financial and operational information supporting the request would have to be filed for the time period from the provider’s last rate review. 

 

Charging providers willing to stay at current rates would be required to file, by July 15 of each year, an audited summary financial statement, including total revenue, total expenses, emergency and non-emergency call volume, and a written declaration that no change in the current maximum rates has occurred.

 

2.   By January 1, 2001, the financial summary forms and the full rate request filings shall be on forms issued by the Department of Public Health.  Further, if the department needs additional information pursuant to Sec. 19a-179-21(f)(2) of EMS regulations, DPH must specify the additional the financial and operational information it wants.  

The regulations review subcommittee established by DPH to examine the rate-setting process shall review the regulations concerning rates and issue its report to the Department of Public Health by July 1, 2000.  The health department shall seek to have the regulations revised through the normal regulation review process.  

3.     <![endif]>  The Medicaid rate for ambulance services should be raised.

4.   The determination of need process shall be streamlined by allowing providers the opportunity to operate any number of vehicles (i.e., ambulances, invalid coaches, and non-transport emergency vehicles) and any number of branches they believe is necessary to render adequate ambulance or invalid coach service.  New services (for ambulance and invalid coach) and services requesting to charge would still be required to go through an initial DON process to prove a need exists before operating.   

Providers shall continue to notify DPH of the number of vehicles they have in service each year and receive a permit for each vehicle in use.  The department may consider the appropriateness of the number of vehicles when analyzing any application for a rate increase.  If, during the normal course of a rate review, the department finds an excessive number of vehicles and branch offices, it may revoke authorization for those vehicles and disallow the expenses related to those vehicles and branch operations for rate determination purposes.  

5.  By January 1, 2001, the Department of Public Health shall collect and maintain data from the ambulance run form.  Data points required to be submitted to DPH shall be uniform by all EMS providers.  Providers shall submit copies of the run form information monthly via a method that accommodates needs of both providers and the department.  The trauma reporting requirements shall be consolidated on this run form to satisfy both general EMS and specific trauma data fields.

By March 2002, and annually thereafter, DPH shall report on the following information which shall include, but not limited to:

·       total number of EMS calls;

·       number of calls requiring each level of service;

·       number of refused calls and number requiring mutual aid response;

·       names of service provider for each level of service; and

·       fractile response times for each level of the EMS system -- dispatch, first response, basic life support, and advanced life support – using common definitions of response times established by the Department of Public Health.  Data may be subject to audit by DPH, as the department deems necessary.

The report shall compile the information and report it in an aggregated format by town – with towns grouped according to urban, suburban, and rural categories – and make the information publicly available, including through DPH’s web site.  The department shall notify the Public Health Committee of the report’s availability.

If a provider does not comply with the submission of required data for a period of six months, or if DPH has cause to believe the provider knowingly and intentionally submitted incomplete or false information, DPH shall notify the provider and the towns served by the provider that compliance is mandatory.  If full compliance is not achieved within the following quarter, DPH shall hold a hearing at which the provider would be required to demonstrate why the PSA assignment should not be removed.  

In addition to EMS providers, each public safety answering point (PSAP) shall, beginning January 1, 2001, submit quarterly aggregated data on its EMS calls to the Office of Statewide Emergency Telecommunications (OSET), within the Department of Public Safety.  The data submitted from PSAPS shall include all 9-1-1 calls where a medical emergency is involved.  The aggregated data shall report elapsed time for dispatch -- from the time the call was received to the time the call was dispatched or transferred -- and shall be reported in fractile response times.  

6. Beginning July 1, 2000, an allocation of no more than $250,000 annually from the surcharge on phone lines that cover the 9-1-1 system be made to finance data collection, maintenance and reporting for the emergency medical system.  

7.  All Public Safety Answering Points (PSAPs) be required to provide emergency medical dispatch (EMD) or arrange for EMD services to be provided to all callers requiring emergency medical services.  Each PSAP or other entity performing EMD functions shall maintain an EMD program.  The Office of Statewide Emergency Telecommunications shall provide oversight of EMD implementation.

Each EMD program shall have, at a minimum, the following characteristics:  1) use only trained EMDs to provide medical interrogation, prioritization, and pre-arrival instructions; 2) use a medically approved emergency medical dispatch priority reference system; 3) provide a continuing medical dispatch education program; 4) implement a quality assurance program that, at a minimum, includes the monitoring of EMD time appropriateness of EMD instructions and EMD dispatch protocols; 5) employ a mechanism to detect and correct discrepancies between established protocols and actual EMD practice; and 6) provide for EMS physician medical direction.

In recognition of the initial start-up costs in providing EMD, program review staff recommends OSET reimburse PSAPs for the costs related to the initial training of dispatchers and for purchasing an emergency medical dispatch priority reference system.  Regional communication centers (i.e., Consolidated Medical Emergency Dispatch – CMEDs) shall also be reimbursed for the initial training and card sets for EMD if they are providing this service for a PSAP.  OSET shall approve for use in Connecticut any national or locally developed EMD course that meets the requirements of NHTSA National Standard EMD Curriculum. 

A four-year phase-in for this requirement is recommended.  This will allow OSET at least one year to select appropriate training providers and establish an administrative mechanism to oversee the training.  PSAPs would also decide whether to provide EMD themselves or establish a system where callers could be transferred to an EMD provider.  In addition, committee staff recommends all PSAP dispatchers performing EMD be trained over a three-year period.  PSAPs must provide an affirmative statement to OSET that they either have in place all the elements of an EMD program identified above or transfer to a provider who does within that four-year time frame.  This affirmation must be received before any reimbursement from OSET takes place.

8.  Department of Public Health leadership communicate to department employees and the regulated EMS community the department’s intention to discharge its regulatory and administrative responsibilities in the EMS area diligently and uniformly.